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Surgical management of chronic temporomandibular joint dislocations

Article  in  Indian Journal of Dental Research · July 2018

DOI: 10.4103/ijdr.IJDR_493_18

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Original Research

Surgical Management of Chronic Temporomandibular Joint Dislocations

Abstract Balaji SM,

Introduction: Temporomandibular joint dislocation is described as the movement of mandibular Preetha Balaji1
condyle out of the fossa beyond its anatomical and functional boundaries causing pain and Director and Consultant,
discomfort. It is often managed by conservative methods, but in long‑standing, chronic conditions, Department of Oral and
surgical treatment is the only option. The goal of surgical treatment is to reposition the condyle Maxillofacial Surgery,
and prevent further recurrences. Materials and Methods: This retrospective analysis involving a Balaji Dental and Craniofacial
single center and a surgeon with 19 patients and 23 joint surgeries performed over a 10‑year period. Hospital, 1Consultant,
Patients who fulfilled inclusion and exclusion criteria and had earlier undergone surgical correction Department of Oral and
with hook‑shaped miniplates and miniscrews fixed with or without bone grafts formed the study Maxillofacial Surgery,
Balaji Dental and Craniofacial
group. Results: In all, 12 were female  (mean age, 41.9  ±  12.07  years) and the rest 9 were male
Hospital, Chennai, Tamil Nadu,
(mean age, 39.8  ±  13.6  years), ranging from 32  years to 58  years. All patients had the dislocation India
for an average period of 19.26  ±  12.6  months before the surgery. The mean maximal mouth
opening  (without pain) preoperatively was 17.78  ±  2.13  mm  (12–25  mm) while postoperatively
it was 32.28  ±  3.17  mm  (27–37  mm). There were no immediate or late surgical complications in
the follow‑up period that ranged from 8 to 37  months. Discussion: When proper case selection
is employed and properly done, using hook‑shaped miniplates with or without bone graft is more
cost‑effective, giving excellent short‑  and long‑term effects. Conclusion: The results in this Indian
population are very similar to that reported from other parts of the world.

Keywords: Hook‑shaped miniplates, India, joint dislocation, pseudarthrosis of temporomandibular

joint, temporomandibular joint dislocation, temporomandibular joint pain

Introduction their lifetime and accounts for 3% of all

The temporomandibular joint  (TMJ),
the only visible movable joint in the
cranium, is a joint involving the parts
of the temporal bone and the condyle
of the mandible. It is best described
as a “ginglymoarthrodial” joint as it is
both a ginglymus (hinging joint) and an
arthrodial  (sliding) joint. The basic range
of movements of a normal TMJ includes
protraction (sliding of the condyle in the
forward direction), retraction (sliding of the
condyle to its original position), elevation
(closing of the jaw), depression (opening of
the jaw), and lateralization.[1]
TMJ dislocation is a common pathology
of the joint where the mandibular condyle
moves out of the glenoid fossa. In extreme
cases, the posterior articulating surface
of the condyle advances in front of the
articular eminence of TMJ. This pathology
reportedly occurs at least once in up
to 7% of the general population during
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For reprints contact: reprints@medknow.com
articular body luxations.[2,3] The disorder
is commonly associated with trauma, most
common in the 3rd  to 4th  decades of life,
with debatable gender predilection.[2,4]
The pathogenesis of TMJ dislocation is
reported to be multifactorial. It occurs
frequently as a result of the following one
or more situations: abnormal structural
components  (such as laxity in capsular
tissue, weak ligaments, steep eminence,
abnormal condylar shape, and atypical
disc position); systemic diseases (such as
involving abnormal collagen  –  Marfan’s
Address for correspondence:
syndrome and Ehlers–Danlos syndrome); Dr. Balaji SM,
neurodegenerative/neurodysfunctional Balaji Dental and Craniofacial
diseases  (such as Huntington’s disease, Hospital, 30, KB Dasan Road,
Teynampet, Chennai ‑ 600 018,
epilepsy, Parkinson’s disease, and multiple
Tamil Nadu, India.
sclerosis); muscle dystrophies/dystonias;
E‑mail: smbalaji@gmail.com
use of drugs such as phenothiazines
or metoclopramide; iatrogenic damage
during procedures such as intubation/ Access this article online
laryngoscopy; dental, ear, nose, and throat
Website: www.ijdr.in
procedures; gastrointestinal endoscopies;
DOI: 10.4103/ijdr.IJDR_493_18
and/or trauma.[2,5]
Quick Response Code:
The management ranges from conservative
to surgical approach depending on cause,
How to cite this article: Balaji SM, Balaji P. Surgical
management of chronic temporomandibular joint
dislocations. Indian J Dent Res 2018;29:455-8.

© 2018 Indian Journal of Dental Research | Published by Wolters Kluwer - Medknow 455
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Balaji and Balaji: Chronic TMJ dislocation surgeries

etiology, precipitating and predisposing factors, age, and autologous bone graft  (iliac or calvarial bone) was adapted
the extent of abnormalities and has been reviewed in and fixed in the glenoid fossa, placed, and fixed into the
depth earlier.[2] There is a paucity of reports of successful concave site of the hook‑shaped miniplate with miniscrews.
management of such chronic TMJ dislocation in this part of The articular eminence periosteum was elevated with
the world.[6‑9] This paper intends to present a single‑center a bone dissector  [Figure  3b]. The miniplate was fixed
experience of surgical management of such chronic TMJ at the anteroinferior region of the articular eminence at
dislocation [Figure 1]. an appropriate place such that the hook would hinder
abnormal motion, but would not hinder normal functioning
Materials and Methods of the TMJ  [Figure  3c]. This was checked by forced
A retrospective analysis of 19  patients and 23 joints that opening of the mouth, wherein the condyle was unable to
were not amenable to conservative management and treated advance beyond the articular eminence. After checking, the
with hook‑shaped miniplates with miniscrews between incisions were closed in layers [Figure 3d]. Appropriate rest
June 2007 and June 2016 formed the subjects of the
present study. As this is a retrospective study involving
only depersonalized data, clearance from the institutional
review board was not necessary.
From case records, all relevant details were collected.
Of the total 19  patients, 12 were female  (mean age,
41.9  ±  12.07  years) and the rest 9 were male  (mean age,
39.8  ±  13.6  years), ranging from 32  years to 58  years.
All patients had the dislocation for an average period of
19.26  ±  12.6  months before the surgery. Conservative and
minimal interventions for dislocation failed and surgical
treatment was employed as the last option. After ruling out/
addressing all possible, known relevant etiological factors,
a
radiological examination was performed [Figure 2]. Criteria
for surgery were extreme limitation of jaw movements or
regional pain while eating, prominent dislocation (clinically
and/or radiologically), and multiple episodes of TMJ
dislocation, hindering normal day‑to‑day activities. Cases
where pseudojoint formation had occurred were excluded
as pathoses were significantly different. All cases were
operated at the author’s center by the author himself.
Surgery was performed under general anesthesia with a
preauricular approach using the procedure of Ellis and
Zide [Figure 3a].[10] A miniplate was modified appropriately
to be shaped like a hook, and if required, additional

b
Figure 1: Mandibular deviation to the right side in a patient with left-sided Figure 2: Computed tomography scan images of temporomandibular joint
temporomandibular joint dislocation dislocation. (a) Mouth closed. (b) Mouth open

456 Indian Journal of Dental Research | Volume 29 | Issue 4 | July-August 2018

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Balaji and Balaji: Chronic TMJ dislocation surgeries
a b
c d
Figure 3: (a) Miniplate placed over markings for fixation in the
temporomandibular joint. (b) Dissection exposing the articular eminence.
(c) Fixation of miniplate at the anteroinferior region of the articular eminence
and condyle. (d) Incision closed with sutures
and antibiotic and nonsteroidal anti‑inflammatory coverage
were provided. Performing substantial postoperative
physiotherapy was advised in all cases to prevent any
possible arthrosis or pseudankylosis and was initiated as
early as the 7th postoperative day.
Results
The duration of the postoperative follow‑up period
was 8–37  months. The mean maximal mouth opening
(without pain) preoperatively was 17.78  ±  2.13  mm
(12–25 mm) while postoperatively it was 32.28 ± 3.17 mm
(27 to 37  mm). There were no immediate or late surgical
complications. Few of the patients who had pain while
performing postoperative physiotherapy were managed
pharmacologically. No instance of miniplate failure or
infection occurred. In all cases, there was sufficient
relief and no instance of recurrent dislocation was
observed  [Figure  4]. One‑sided partial, temporary facial
paralysis for 3  weeks was observed in one bilateral TMJ
dislocation case. All cases were comfortable during
execution of normal range of TMJ motion during follow‑up
and no instance of abnormal jaw “clicking” noise was felt
or reported by any of the patients.
Discussion
Anatomically, TMJ dislocations are classified as follows:
Type  I  –  condylar head is below the tip of the eminence,
Type  II  –  condylar head is in front of the tip of the
eminence, and Type  III  –  the condylar head is high up in
front of the base of the eminence.[11] The surgical goals
must continue to be to reduce or return to normal TMJ
anatomy, improve function, and restore normal occlusion
with the procedure posing no or minimal morbidity and
squeal (risk of ankylosis) as well as eliminating the chance
of recurrence.[12] There is no universally single algorithm
followed to fetch desired result. However, the treatment
Indian Journal of Dental Research | Volume 29 | Issue 4 | July-August 2018 
Figure 4: Postoperative photograph of the patient
algorithm and steps suggested by Marqués‑Mateo et al. are
widely recommended.[2]
In the present cases too, all cases were long standing
than those suggested by Marqués‑Mateo et  al., but at a
much younger age and more common among females, as
reported by Rattan and Arora reports.[2,12] There could be
the difference in the study population characteristics as
our values are much closer to Indian population report by
Rattan and Arora.[2,12]
As the patients presented with the disease, the
etiopathogenesis and exact causative factors could not be
elicited owing to poor oral history and potential bias.
Although there are several conservative techniques
mentioned, surgical options include open reduction,
condylar resection or reduction, increase or decrease in
the height of the eminence, removal or repositioning of
the meniscus, sometimes extended with coronoidectomy,
and/or the kind of the surgery with hooks.[2] To achieve
the goals of surgical management, procedures such as
capsulorrhaphy, meniscectomy, eminectomy, capsular
ligament plication, and shortening are performed, but
come with complications such as facial asymmetry and a
limited degree of jaw movement while the present method
employed has been proved to be reliable and time tested,
if performed properly.[1] The presence of a foreign body
in joint space, possibilities of improper positioning or
loss of stability of screw fixation, and miniplate fractures
are some of the potential complications, but if adequately
planned, limitation of jaw movements can be effectively
overcome.
The present series of cases provides evidence that TMJ
dislocation in India is not different from the rest of the
world. The case selection, understanding etiopathogenesis,
and instituting appropriate therapy would give the best
results. For the conditions described, the technique
presented herein provides good long‑term relief, especially
when all other conservative treatment methods fail.
457
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Balaji and Balaji: Chronic TMJ dislocation surgeries
Conclusion
A single‑center experience of surgical management of
TMJ dislocation is presented. Effective treatment planning
is required to minimize complications, and if performed
optimally, hook with or without graft provides the best,
long‑standing results, increasing the quality of life of
patients.
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form the patient(s) has/have
given his/her/their consent for his/her/their images and
other clinical information to be reported in the journal. The
patients understand that their names and initials will not
be published and due efforts will be made to conceal their
identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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Indian Journal of Dental Research | Volume 29 | Issue 4 | July-August 2018